Simple Touch Board and Care

Allegation investigated: Staff did not refund authorized representative after residents death

At 11:30am, Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced visit in response to the above-mentioned allegation. LPA met with the Staff 1 (S1), who granted access to facility. LPA contacted the Administrator, Karine Sarkisyan, and explained the reason for the visit. LPA was informed that the Administrator is currently out of town and is unable to come to the facility. The Administrator designated S1 to sign for the report. At 11:35Am, LPA requested resident and staff roster. At 11:40am, requested copies of pertinent information which include, but not limited to facility's Admission Agreement, Copy of Invoice/Check, etc. relevant to the investigation. At approximately 11:50am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected. Between 11:50am - 12:30pm, LPA conducted an interview with the Administrator and conducted review of facility Admission Agreement. Continue on LIC9099-C Substantiated Allegation: Staff did not refund authorized representative after residents death It was alleged that staff failed to provide a refund to Resident #1 (R1)’s family after R1 passed away. R1 was admitted on 07/29/2026, paid $3000 for a month of care, and passed on 08/07/2026. R1’s representative confirmed there were no belongings to remove and that the family requested a refund but never received one. Although the Administrator later stated she was willing to issue the refund, text messages show she instead directed the family to the hospice agency for financial matters. Under the admission agreement, Health and Safety Code 1569.652, and Assembly Bill 261, the facility is required to provide a refund within 15 days once a resident’s belongings are removed. Based on interviews and record review, the allegation is Substantiated. Deficiency will be issued on LIC9099-D. Exit interview conducted. Appeal rights explained and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Aug 12, 2026 · control 31-AS-20260812092155

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.652(c) · Plan of correction due date: Aug 19, 2026

Termination of admission agreement upon death of resident; removal of resident’s... A refund of any fees paid in advance covering the time after the resident’s personal property has been removed... within 15 days after the personal property is removed. This requirement is not met as evidenced by: Based on record review & interview, licensee did not issue a refund after R1 passed away and had no personal belonging to be removed. This posed a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 12, 2026

Plan of correction: Administrator will have to pay the prorated amount to R1's responsible party for the remaining days after R1 passed away (R1 had no belongings) R1's rate for basic services was $3000/ month at the time of passing. During today's visit prorated amount was Zelled to R1's representative POC is cleared during the visit.

Allegation investigated: Staff do not prevent resident from wandering from the facility

This is an Amendment to the original report issued 05/19/2026. Additional information was added to clarify the investigation. At 10:00am, Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced initial 10-day complaint investigation regarding the above allegation. The LPA met with the Administrator and explained the reason for the visit. During course of the investigation, interviews and record review were conducted. At 10:05am, LPA requested resident and staff roster. At 10:10am, LPA requested copies of pertinent information which included but not limited to Admission Agreement, Physician’s Report, Preplacement Appraisal Information and Appraisal Needs and Services Plan, relevant to the investigation. However, LPA observed that all documents are incomplete and missing dates and signatures. Continue on LIC9099-C Substantiated At approximately 10:25am, the LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 10:30am – 11:30am, the LPA conducted an interview with the Administrator, two (2) witnesses and attempted to interview one (1) out of three (3) residents. Allegation: Staff do not prevent resident from wandering from the facility The facility is alleged to have failed to provide adequate supervision to Resident 1 (R1), who has a mental health diagnosis, a history of wandering, and is not supposed to leave unassisted. Witnesses reported seeing R1 walking alone in the neighborhood on multiple dates (04/28/26, 05/08/26, and 05/09/26), with emergency services contacted each time. The Administrator acknowledged that staff cannot physically stop R1 due to combative behavior and only observe R1 from a distance rather than preventing elopement. No plan was provided to address R1’s exit-seeking behavior (i.e. develop and implement a formal care plan for R1, increase staff monitoring, implement structured engagement activities, debrief and train staff, notify and collaborate with healthcare professionals, etc.). The Administrator was also unable to provide staff training in dementia-related behaviors and non-physical redirection techniques. Lastly, LPA conducted record reviews and observed that R1’s Pre-placement Appraisal was incomplete and unsigned, and the Physician’s Report—which stated R1 could leave unassisted—was missing a physician’s signature, rendering it invalid. Therefore, based on interviews and facility record reviews, this allegation is Substantiated. Deficiencies issued per Title 22. Exit interview conducted appeal rights explained and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, May 19, 2026 · control 31-AS-20260511130957

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(4) · Plan of correction due date: May 20, 2026

Additional Personal Rights for Residents in Privately Operated Facilities: (4) To care, supervision, and services... and are delivered by staff that are sufficient in numbers qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on LPAs record review and observation, licensee did not comply with the section cited above by failing to properly conduct R1's pre-assessment and to assure that the staff is trained to provide proper care and supervision to meet R1's needs. This poses an immediate health, safety risk to persons in care.the state’s words, verbatim · CDSS document, May 19, 2026

Plan of correction: Administrator agreed to schedule vendorized training for all staff and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(d)(1-5) · Plan of correction due date: May 20, 2026

Administrator Qualifications: d) The administrator shall have the qualifications... all requirements for an administrator shall apply. 1)Knowledge of the requirements for providing care and supervision appropriate to the residents... This requirement is not met as evidenced by: Based on interviews and record reviews the licensee did not comply with the section cited above by failing to provide appropriate care and supervision to R1, submit incident reports in a timely manar, provide appropriate trainilng to staff, have the staff associated/fingerprinted prior to employement, etc., which poses an immediate health, safety risk to persons in care.the state’s words, verbatim · CDSS document, May 19, 2026

Plan of correction: Administrator agreed to schedule vendorized training for all staff and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion

Type of visit: Case Management - Deficiencies

At 10:00am, Licensing Program Analyst (LPA) Angela Panushkina conducted unannounced visit to this facility in conjunction with a complaint, control # 31-AS-20260511130957. LPA met with the Administrator and explained the reason for the visit. During the visit, LPA was informed of the following: · S1 started working here as of 05/07/2026. LPA conducted review of Licensing Information System and did not observe S1's association to this facility. LPA informed the Administrator that all staff members must be fingerprint cleared and associated prior to employment. · Administrator informed the LPA that R1 moved to this facility on 04/28/2026. LPA was also informed that R1 would go outside and interact with neighbours, however on 05/08/26 and 05/09/26 R1 wondered around the neighborhood, and the staff was unable to redirect R1 due to R1's combative behavior. LPA was informed that on both days 911 was initiated. However, no incident report was submitted to the Community Care Licensing Department (CCLD) in a timely manner. LPA reviewed all incident reports on a system and did not observe an Incident Report regarding R1. In addition, the Administrator admitted that no incident was submitted to the Regional Office (RO). Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPAs informed the Administrator that all staff members are mandated reporters and they are all responsible for reporting. · LPA was unable to obtain any staff/resident records. The Administrator informed LPA that three (3) residents were admitted within the same week, along with S1. Administrator informed LPA that she was unable to complete any of the files. No documents were provided to LPA during todays visit. Only R1's facility file was available, however, all documents were not valid due to being incomplete and or missing signatures/dates. Continue on LIC809-C · Lastly, the LPA addressed overdue licensing fees. At this time the facility has three (3) residents and facility is still accumulating Licensing Fees. The facility’s anniversary date was 01/03/26. The total amount due is $1,484.00. LPA also informed the Administrator that if corrections are not made then Licensee / Administrator maybe called into the Community Care Licensing Division (CCLD) office for an Informal Conference and / or a Non-Compliance meeting. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are cited and noted on LIC 809-D. Exit interview conducted, appeal rights and copy of report signed and delivered.the state’s words, verbatim · CDSS document, May 19, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)A,B&D · Plan of correction due date: May 26, 2026

Requirements (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)... This requirement is not met as evidenced by: Based on interviews and record reviews, conducted by LPA, the licensee did not comply with the section cited above by failing to notify CCLD regarding regarding incidents with R1 on 5/8/26 & 5/9/26, which posed potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 19, 2026

Plan of correction: Licensee shall ensure a written report is submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events. R1's incident report shall be submitted to LPA by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(b)(15) · Plan of correction due date: May 26, 2026

Resident Records: (b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal... This requirement is not met as evidenced by: Based on LPAs inspection and observation, the licensee did not comply with the section cited above. R1 was admitted on 04/28/26 and all of R1's records were incomplete and missing signatures/dates, which posed potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 19, 2026

Plan of correction: Licensee agreed to review and complete all facility residents' files. Licensee/administrator will submit a written statement notifying the department what steps will be taken to clear this deficiency and to ensure such deficiency will not reoccur.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.185(a)(1) · Plan of correction due date: May 26, 2026

Fees for license... (a)(1) An application fee adjusted by facility and capacity shall be charged... After initial licensure, a fee shall be charged by the department annually on each anniversary. This requirement was not met as evidenced by: Based on record review, the licensee did not comply with the section cited above by not paying the annual licensing fees for the total amount due of $1,484.00, which poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, May 19, 2026

Plan of correction: The licensee has agreed to pay the annual licensing fees in total amount of $1484.00 by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: May 20, 2026

Criminal Record Clearance: (e) All individuals subject to a criminal record review... shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above. S1's first day of work was on 05/07/26 and as of 05/19/26, S1 is not associated to the facility, which poses an immediate health, safety risk to persons in care.the state’s words, verbatim · CDSS document, May 19, 2026

Plan of correction: During today's visit Administrator provided a letter of clearance for S1 (dated on 04/30/26). Administrator agreed to associate S1 get through the guardian and provide an updated LIC500 to reflect the new staff.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Panushkina conducted an annual visit, met with the Administrator and explained the reason for the visit. A tour of the physical plant was initiated at 10:45am and the following were observed: The facility maintains a comfortable temperature at 70°F. LPA was informed that the facility did not have any residents since September 2025. KITCHEN: The kitchen area that is equipped with a refrigerator, microwave oven and sink. All sharps observed to be locked in a kitchen drawer. All chemicals are locked under the kitchen sink and or in the garage and kept inaccessible to residents in care. The fire extinguisher is located in the kitchen and was last purchased on 03/31/2026 BEDROOMS: The facility has five (5) bedrooms designated for residents’ use. All bedrooms are furnished with beds, dressers and required bedding and linen. The bedrooms have sufficient closet space and lighting. Room #6 is designated for live-in staff. BATHROOMS: The facility has three (3) bathrooms. LPA observed all bathrooms have non-skid mat, soap, paper towels and hand washing signs. Extra towels and linens were readily available. MEDICATION ROOM: At approximately 11:00am, LPA observed medications are centrally stored and locked, in the hallway closet and inaccessible to residents in care. The first-aid kit has been inspected which has at least the following: tweezers, scissors, antiseptic, bandages, gauze, thermometer; including a current First Aid manual. Continue on LIC809-C LAUNDRY ROOM: The laundry room is located by the kitchen. The washer/dryer appears to be in good condition. Laundry supplies are kept inaccessible when not in use with supervision. COMMON AREAS: These include a dining area and a living room. The Common areas are furnished with adequate furniture to accommodate a maximum capacity of six (6) residents. At 11:20am, smoke and carbon monoxide detectors were tested and observed to be operable. There were no visible immediate hazards. SURROUNDING GROUNDS: At approximately 11:30am LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. LPA discussed the importance of maintaining care and supervision to meet the needs of residents. There are no bodies of water. Between 11:30am to 11:45am, LPA reviewed record of two (2) staff, and observed everything to be complete and updated. LPA collected Certificate of Liability Insurance and LIC500. No citations were issued during this visit. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Apr 1, 2026

Allegation investigated: Staff left residents unattended in the facility for an extended period of time.

At 09:00am, Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced initial 10-day complaint investigation regarding the above allegations. LPA met with Staff 1 (S1), who granted access to the facility. The Administrator arrived shortly after, and LPA explained the reason for the visit. During course of the investigation, interviews and record review were conducted. At 09:05am, LPA requested resident and staff roster. At 09:10am, LPA requested copies of pertinent information which include, but not limited to Admission Agreement, Physician's Report, relevant to the investigation. At approximately 09:15am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected. Between 09:20am – 11:00am, LPA conducted an interview with the Administrator, one (1) staff and attempted to interview two (2) out of two (2) residents. However, due to their metal condition/diagnoses, residents were not able to communicate and or answer questions. Continue on LIC9099-C Substantiated Allegation: Staff left residents unattended in the facility for an extended period of time. It was alleged that on 09/10/25, S1 was locked out of the facility for approximately three hours, from 3:30pm to 6:30pm, leaving two (2) residents inside unattended. LPA conducted an interview with S1 and was informed that on 09/10/25, S1 took the trash out (about 3:30pm) and when tried to go back inside the house, the wind shut the front door and due to the knob disrepair, the door got locked and there was no other way to get inside. S1 stated that the phone was left inside the house and S1 was unable to contact the Administrator. Moreover, S1 was unable to go around the house because both side doors/gates were locked. LPA was also informed that the two (2) neighbors, across the street, have dogs and S1 was afraid to approach the house and ask for help. Instead, S1 waited for the next-door neighbor to arrive home before the help was provided. S1 asked the neighbor #1 (N1) for help and N1 contacted neighbor #2 (N2) to find the phone number for the Administrator. N2 was able to locate the phone number online and S1 contacted the Administrator at 5:55pm. However, the Administrator informed S1 that she would be there in an hour. With the help of neighbors, S1 checked the windows and discovered one that was unlocked and S1 crawled into the house through the window at 6:30pm. LPA was not able to interview two (2) out of two (2) residents due to their mental condition. However, LPA conducted interviews with two (2) neighbors/witnesses who confirmed the statement provided by S1. During today’s visit, LPA observed the front doorknob, from the inside, is still in disrepair. Interview with the Administrator revealed that she was not aware of this issue. LPA also observed that both side doors/gates have padlock and require a key to open. Interview with the Administrator revealed that they keep the gates locked due for security purposes. Therefore, based on interviews and information gathered during today’s visit, this allegation is Substantiated. Deficiency is cited on LIC 9099-D. Exit interview conducted. Appeal rights explained and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Sep 26, 2025 · control 31-AS-20250921123305

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Sep 28, 2025

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities... (4) To care, supervision, and services that meet their individual needs and are delivered by staff... ... to meet thier needs. This requirement is not met as evidenced by: Based on interviews conducted, licensee did not comply with the section cited above by leaving two (2) residents unattended in the facility from 3:30pm to 6:30pm, which posed an immediate health and safety risk to persons in carethe state’s words, verbatim · CDSS document, Sep 26, 2025

Plan of correction: Administrator agreed to schedule vendorized training for all staff by 09/28/25 and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion *** Civil Penalties Assessed on LIC421M***

Type of visit: Case Management - Deficiencies

At 9:00am, Licensing Program Analyst (LPA) Angela Panushkina conducted unannounced visit to this facility in conjunction with a complaint, control #31-AS-20250921123305. LPA met with Staff #1 (S1), Sandugash Shaldanbayeva, who granted access to the facility. The Administrator arrived shortly after and LPA explained the reason for the visit. Upon arrival LPA observed the following: S1 is not associated with the facility Front doorknob is broken/in disrepair. Both side doors/gates have padlock and require a key to open. During the visit, LPA also conducted review of all incident reports on a system and did not observe an Incident Report submitted to the Community Care Licensing Department (CCLD) in a timely manner. In addition, the Administrator admitted that no incident was submitted to the Regional Office (RO). Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPAs informed the Administrator that all staff members are mandated reporters, and they are all responsible for reporting. LPA informed the Administrator to submit an incident report that occurred on: · 09/10/2025 Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are cited and noted on LIC 809D.the state’s words, verbatim · CDSS document, Sep 26, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(6) · Plan of correction due date: Sep 28, 2025

Additional Personal Rights of Residents in Privately Operated Facilities: (a) In addition to the rights... resident shall have all of the following personal rights: (6) To make choices concerning their daily lives in the facility. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by placing a lock on both side gates. This poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 26, 2025

Plan of correction: Administrator shall remove the lock that require key on entrance/exit side doors and submit picture proof. In-service training will be conducted with all staff and copy of the training will be submitted to LPA by POC date

From the deficiency page — Deficiency type: Type A · Section cited: CCR87355(e)(2) · Plan of correction due date: Sep 26, 2025

Criminal Record Clearance: (e) All individuals subject to a criminal record review... shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified... This requirement is not met as evidenced by: Based on (LIS) record review, the licensee did not comply with the section cited above. S1's first day of work was on 09/09/25 and as of 09/26/25, S1 is not associated to the facility which poses an immediate health, safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 26, 2025

Plan of correction: Administrator has agreed to have S1 get fingerprinted. Administrator will provide an updated LIC500 to reflect new staff.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(A,B,&D) · Plan of correction due date: Oct 3, 2025

Requirements: (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)... This requirement is not met as evidenced by: Based on interviews and record reviews conducted by LPA, the licensee did not comply with the section cited above by failing to notify CCLD regarding two residents being left unattended by S1 on 09/10/25, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 26, 2025

Plan of correction: Licensee shall ensure a written report is submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events. Incident report shall be submitted to LPA by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Oct 3, 2025

Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by: Based on LPAs observation, on 09/26/25 visit, the licensee did not comply with the section cited above. LPA observed front doorknob is broken, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 26, 2025

Plan of correction: Administrator will replace the broken doorknob/lock and submit proof of picture to LPA by POC date.

Type of visit: Case Management - Deficiencies

At 9:00am, Licensing Program Analyst (LPA) Angela Panushkina conducted unannounced visit to this facility in conjunction with a complaints, control #31-AS-20250703001325. LPA met with Staff #1 (S1), Karine Hakopyan, who granted access to the facility. LPA also contacted the Administrator and the team explained the reason for the visit. During the visit, the team was informed of the following: S1 started working here as of 06/23/2025. LPA conducted review of Licensing Information System and did not observe S1's association to this facility. LPA informed the Administrator that all staff members must be fingerprint cleared and associated prior to employment. Administrator informed the LPA that R1 moved to this facility on 06/01/2025. LPA was also informed that later that day, around 8:00pm, 911 was called for R1 and R1 was taken to the hospital (Emergency Room). However, no incident report was submitted to the Community Care Licensing Department (CCLD) in a timely manner. LPA reviewed all incident reports on a system and did not observe an Incident Report regarding R1. In addition, the Administrator admitted that no incident was submitted to the Regional Office (RO). Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPAs informed the Administrator that all staff members are mandated reporters and they are all responsible for reporting. LPA was unable to obtain any staff/resident records. The Administrator informed LPA that the Staff has no access to facility records/documents. Administrator can arrive to the facility after 1:00pm and provide all documents. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are cited and noted on LIC 809D. Exit interview conducted, appeal rights and copy of report signed and delivered.the state’s words, verbatim · CDSS document, Jul 3, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)A,B&D · Plan of correction due date: Jul 5, 2025

Requirements (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)... This requirement is not met as evidenced by: Based on interviews and record reviews, conducted by LPA, the licensee did not comply with the section cited above by failing to notify CCLD regarding the 911 call for R1 on 06/01/25, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 3, 2025

Plan of correction: Licensee shall ensure a written report is submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events. R1's incident report shall be submitted to LPA by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87755(b) · Plan of correction due date: Jul 10, 2025

Inspection Authority of the Licensing Agency: (b) The licensee shall ensure that provisions are made for private interviews with any resident or any staff member; and for the examination of all records relating to the operation of the facility. This requirement is not met as evidenced by: Based on interviews and record reviews, conducted by LPA, the licensee did not comply with the section cited above by failing to provide resident/staff records upon request, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 3, 2025

Plan of correction: Administrator agreed to submit LIC308, LIC500 and an adendum to their peronnel policies that specify that the Designee will be available any time, while the Administrator is not available, and have full access to the records. Proof will be submitted to LPA by POC date

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Jul 4, 2025

Criminal Record Clearance: (e) All individuals subject to a criminal record review... shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above. S1's first day of work was on 06/23/25 and as of 07/03/25 S1 is not associated to the facility, which poses an immediate health, safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 3, 2025

Plan of correction: Administrator has agreed to have S1 get fingerprinted. Administrator will provide an updated LIC500 to reflect the new staff.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Jul 10, 2025

Administrator - Qualifications and Duties: (a) All facilities... When the administrator is not in the facility, there shall be coverage by a designated substitute... responsible and accountable for management and administration of the facility as specified... This requirement is not met as evidenced by: Based on interviews and record reviews, conducted by LPA, the licensee did not comply with the section cited above by failing to have a Designee who's responsible, acountable for management and administration of the facility. This poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jul 3, 2025

Plan of correction: Administrator agreed to submit LIC308, LIC500 and an adendum to their peronnel policies that specify that the Designee will be available any time, while the Administrator is not available, and will have full access to the records. Proof will be submitted to LPA by POC date

Type of visit: Required - 1 Year

At 10:00am, Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced annual visit. LPA met with the Administrator and explained the reason for the visit. There is one entrance being utilized at the facility. The facility has a total of five (5) bedrooms and three (3) bathrooms. The facility is fire cleared for six (6) non-ambulatory, of which one (1) can be bedridden in room #5. Facility is also approved to have six (6) hospice residents. At 10:15am, LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. Food storage and preparation areas are clean and inaccessible to pests. All knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents. Laundry is located in a kitchen area and attached garage and kept locked and inaccessible to residents. At approximately, 10:25am LPA observed medications are centrally stored and locked in the cabinet, in a hallway and inaccessible to residents in care. There are five (5) bedrooms designated for residents use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Facility has an awake staff. Auditory alarms were tested and observed to be operational. At 11:45am LPA observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured at 116.1°F. LPA observed appropriate grab bar and had non-skid mat. All trash cans in bathrooms had fitted lids to protect from cross contamination. Continued on LIC 809-C The facility maintains a comfortable temperature at 73°F. The smoke and carbon monoxide detectors are hardwired, interconnected and at 10:45am, LPA tested and observed to be operational. Fire extinguisher is located in the kitchen, and was purchased on 06/14/2024. At approximately, 10:55am LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents. There are no bodies of water. LPA collected Certificate of Liability Insurance, Administrator Certificate and LIC500. Facility is within CA code of Regulations Title 22 or Health and Safety Code. No deficiencies were issued. Exit interview conducted and copy of report signed and delivered.the state’s words, verbatim · CDSS document, Jan 17, 2025

Allegation investigated: Facility staff are unable to communicate with residents

At 9:00am, Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced initial 10-day complaint investigation regarding the above allegation. LPA met with the staff, Gegham Amirkhanyan, who granted access to the facility. The staff contacted the Administrator and the LPA explained the reason for the visit. The Administrator was unable to come to the facility and designated the current staff to sign for the report. During course of the investigation, interviews and record review were made. At 09:05am, LPA requested resident and staff roster. At approximately 09:15am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 09:20am – 10:30pm, LPA conducted an interview with the Administrator, one (1) staff, and three (3) residents. Continue on LIC9099-C Substantiated Allegation: Facility staff are unable to communicate with residents On 12/11/24, Licensing Program Analyst (LPA) Angela Panushkina and Regional Director, LTC Ombudsman Program, Ginger Perini conducted a complaint visit (control #31-AS-20241205141612 and #31-AS-20241209084739). During that visit, Staff #1 (S1) was working here and upon arrival the team attempted to communicate with S1 in English. The team observed that S1 did understand basic questions when asked in English, however S1 was unable to answer. S1 informed LPA that residents have used a translator app and written translations from Russian to English to be able to communicate. Moreover, residents interviewed did acknowledge that there is a language barrier, however they all agreed that for the most part they can get their point across. Interview with the Administrator confirmed that she is aware that S1 is not fluent in communicating in English and informed LPA that she’s always at the facility during the day and is able to assist with communication and at night, S1 can call her to assist with any translations. During today's visit, LPA was informed that as of 12/11/24, S1 no longer works here. Based on interviews and observation, the allegation is deemed SUBSTANTIATED. Deficiency is cited on LIC 9099-D. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Dec 19, 2024 · control 31-AS-20241216084841

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(3) · Plan of correction due date: Dec 26, 2024

Personnel Requirements - General: (d) All personnel shall... have related experience in the job assigned to them. (3) Skill and knowledge required to provide necessary resident care... including the ability to communicate with residents. This requirement is not met as evidenced by: Based on observations and interviews, during 12/11/24 visit, the licensee did not comply with the section cited above to ensure that S1, is able to communicate with residents in English. This poses/posed a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 19, 2024

Plan of correction: LPA was informed that as of 12/11/24, S1 is no longer working at this facility. POC cleared during today's visit

Allegation investigated: Facility staff do not provide quality meals to resident(s)

At 9:00am, Licensing Program Analyst (LPA) Angela Panushkina and Regional Director, LTC Ombudsman Program, Ginger Perini, conducted an unannounced initial 10-day complaint investigation regarding the above allegation. The team met with staff, Chinara Atamkulova, who granted access to the facility. Administrator arrived shortly after, and the team explained the reason for the visit. During course of the investigation, interviews and record review were made. At 09:05am, LPA requested resident and staff roster. At 10:10am, LPA requested copies of pertinent information which include, but not limited to Preplacement Appraisal Information, and Facility Menu, relevant to the investigation. At approximately 09:15am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 09:20am – 12:30pm, LPA interviewed the Administrator, one (1) staff, and three (3) residents. Continue on LIC9099-C Substantiated Allegation: Facility staff do not provide quality meals to resident(s) It was alleged that the facility staff do not provide quality meals to resident(s). To investigate this allegation, the team reviewed the menu and the food supply with the staff. The staff was interviewed regarding the meal plan for the day. The facility has two refrigerators and the food supply was checked. The team observed that there were eggs, milk, fruits and vegetable as part of the perishable foods. However, the team did not observe the freezer stocked with adequate perishable foods: a chicken, beef, pork nor fish. The Administrator informed the team that she will do shopping today. Lastly, at 10:15am, the team observed S1 prepared only half (½) grilled cheese with 6oz of orange juice for R2's breakfast. Based on interviews and observation this allegation is Substantiated. Deficiencies issued per Title 22. Exit interview conducted appeal rights explained and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Dec 11, 2024 · control 31-AS-20241205141612

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(a) · Plan of correction due date: Dec 13, 2024

General Food Service Requirements. (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents... All food shall be.. prepared and served in a safe and healthful manner... This requirement is not met as evidenced by: Based on LPAs' inspection and observation, licensee did not comply with the section cited above by preparing a small portion of grilled cheese and orange juice for breakfast, this poses a potential health, safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 11, 2024

Plan of correction: Licensee/Administrator shall develop a plan to ensure facility will maintain sufficient food supply at all times. Submit plan and additional food supply purchased by POC date

Type of visit: Case Management - Deficiencies

At 9:00am, Licensing Program Analyst (LPA) Angela Panushkina and Regional Director, LTC Ombudsman Program, Ginger Perini, conducted unannounced visit to this facility in conjunction with a complaints, control #31-AS-20241205141612 and #31-AS-20241209084739. The team met with Staff #1 (S1), Chinara Atamkulova, who granted access to the facility. Administrator arrived shortly after, and the team explained the reason for the visit. During the visit, the team was informed of the following: Upon arrival the team observed the front entrance locked (padlock) to which staff had to retrieve the key to open the door. Interview with the Administrator and S1 revealed that the door is being locked with a lock from the inside to prevent R1 from leaving the facility. The team was also informed that only the staff has an access to open the lock. S1 started working here as of 12/06/2024. LPA conducted review of Licensing Information System and did not observe S1's association to this facility. LPA informed the Administrator that all staff members must be fingerprint cleared and associated prior to employment. Administrator informed the team that R1 moved to this facility on 11/22/24 and from 11/22/24 to present, R1 refused to take all six (6) prescribed medications. The team observed R1's file missing Admission Agreement, Physician's Report and some forms missing signatures/dates and or incomplete. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are cited and noted on LIC 809D. Exit interview conducted, appeal rights and copy of report signed and delivered.the state’s words, verbatim · CDSS document, Dec 11, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(6) · Plan of correction due date: Dec 13, 2024

Additional Personal Rights of Residents in Privately Operated Facilities: (a) In addition to the rights... resident shall have all of the following personal rights: (6) To make choices concerning their daily lives in the facility. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by placing a lock on a main entry door to preventing R1 from leaving/wondering out. This poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 11, 2024

Plan of correction: Administrator shall remove the lock that require key on entrance/exit door and submit picture proo. In-service training will be conducted with all staff and copy of the training will be submitted to LPA by POC date

From the deficiency page — Deficiency type: Type A · Section cited: CCR87355(e)(2) · Plan of correction due date: Dec 13, 2024

Criminal Record Clearance: (e) All individuals subject to a criminal record review... shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above. S1's first day of work was on 12/06/24 and as of 12/11/24 S1 is not associated to the facility which poses an immediate health, safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 11, 2024

Plan of correction: Administrator has agreed to have S1 get fingerprinted. Administrator will provide an updated LIC500 to reflect new staff.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(b)(15) · Plan of correction due date: Dec 18, 2024

Resident Records: (b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal... This requirement is not met as evidenced by: Based on LPAs inspection and observation, the licensee did not comply with the section cited above. R1 was admitted on 11/22/24 and records were incomplete and or missing documents, which poses/posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Dec 11, 2024

Plan of correction: Licensee agreed to review and complete all facility residents' files. Licensee/administrator will submit a written statement notifying the department what steps will be taken to clear this deficiency and to ensure such deficiency will not reoccur.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Dec 13, 2024

87465 Incidental Medical and Dental Care: c) If the resident's physician has stated in writing... 2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Based on record reviews and interviews, licensee did not comply with the section above to ensure R1 took prescribed medication from 11/22/24-12/11/24. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 11, 2024

Plan of correction: Administrator agreed to schedule vendorized training for all staff by 12/13/2024 and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion

Allegation investigated: Licensee does not ensure that staff are present at the facility while residents are in care. Staff did not seek medical attention for resident in a timely manner. Licensee does not ensure that residents are provided with food that is of the quality and in the quantity necessary to meet their needs.

At 10:00am, Licensing Program Analyst (LPA) Angela Panushkina conducted an unannounced subsequent visit at this facility to investigate the above allegations. LPA met with the Administrator and explained the reason for the visit. During course of the investigation, interviews and record review were made. At 10:05am, LPA requested resident and staff roster. At 10:10am, LPA attempted to request copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, relevant to the investigation. At approximately 10:15am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 10:20am – 12:30pm, LPA interviewed the Administrator, one (1) staff and (two) out of two (2) residents. Continue on LIC9099-C Unsubstantiated Allegation: Licensee does not ensure that staff are present at the facility while residents are in care. It was alleged that the facility Administrator with the spouse (Staff #1) go home at night and no staff are present to provide care to the residents. To investigate this allegation, LPA conducted an interview with the Administrator and S1 and both denied the above allegation. LPA was informed that although the facility has a night shift staff, the Administrator and S1 do not leave the facility premises due to residing at the facility and mostly stay in their room. Two (2) out of two (2) residents interviewed corroborated with the Administrators statement and expressed no concerns regarding this allegation. Lastly, during the physical plant tour, LPA observed the staff room with a private kitchen/dining area and a bathroom available. Based on LPA's observations and interviews this allegation is deemed Unsubstantiated, at this time. Allegation: Staff did not seek medical attention for resident in a timely manner. It was alleged that R1 fell and hurt his/her back, arms and legs (bruising) and the Administrator refused to call 9-1-1. To investigate this allegation, LPA conducted an interview with the Administrator and S1. Both parties interviewed informed LPA that R1 did not have a fall. LPA was informed that on 05/07/24, R1 went out for lunch with friends. Administrator also informed LPA that once R1 came back to the facility, R1 went into his/her room. When Administrator went to check on R1, he/she was walking towards the Administrator with the walker and told the Administrator that his/her legs are giving up. At that point, the Administrator called S1 for help and held R1. R1 slowly was able to seat on the floor. LPA was informed that there was no incident of a fall. Few minutes later, R1 felt better and was placed on a bed. Interview with the Administrator also revealed that although R1's hospice nurse was immediately contacted and R1 was evaluated on that same day, 9-1-1 was called on 05/13/24, due to R1's decline in condition. In addition, Administrator and S1 informed LPA that prior to their employment they completed 40 hours of training, and they are aware of the proper steps on how to assist residents with their medical needs, they immediately contact hospice or emergency services, if needed. Interview with two (2) out of two (2) residents revealed that they feel very safe living at this facility. Both residents also informed LPA that the facility staff is very professional and knowledgeable of their duties. Lastly, review of R1's Medical Records revealed that R1 was diagnosed with atelectasis/pneumonia, and no evidence of bruising nor serious injury were observed upon admission. Based on interviews and record reviews this allegation is deemed Unsubstantiated, at this time. Continue on LIC9099-C Allegation: Licensee does not ensure that residents are provided with food that is of the quality and in the quantity necessary to meet their needs. It was alleged that facility staff failed to provide adequate food service. To investigate this allegation, LPA conducted a physical plant walk through at 10:15am and observed the refrigerator to be fully stocked. Additionally, LPA observed lunch being prepared for the residents, and it was observed to be nutritious. Lastly, LPA conducted interviews with two (2) out of two (2) residents and both residents stated they were happy with the food services and meals they are provided. Based on LPA's observations and interviews, this allegation is deemed Unsubstantiated, at this time. No deficiency cited during today's visit. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Aug 2, 2024 · control 31-AS-20240531162143

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Angela Panushkina conducted unannounced Case Management visit to this facility in conjunction with a complaint control #31-AS-20240606085307. LPA met with the Administrator and explained the reason for the visit. The purpose of this Case Management visit is to address the deficiencies that were observed during the initial complaint investigation conducted on 06/14/24 not related to the complaint. During the file review and Centrally Stored Medication and Destruction Records (CSMDR), LPA observed the following: R1 was admitted to this facility on 05/31/24 with Pro re nata (PRN) and prescribed medications (bubble pack) from the Pharmacy #1. As of 06/04/24 R1 was admitted on Hospice and a new PRN and prescribed medications (bubble pack) were delivered from Pharmacy #2. During the CSMDR record review, LPA observed all medications from Pharmacy #2 were registered/listed. However, two (2) PRN medications from Pharmacy #1 were not registered. Moreover, LPA observed the refill date for those two (2) PRN medications was on 06/05/24, but the PRN log indicated that R1 took/started the pills on 06/03/24 and 06/04/24. LPA conducted an interview with the Administrator who confirmed that R1’s previously ordered PRN medications were not registered in CSMDR, since there were less than five (5) pills left. Deficiency issued per Title 22. Exit interview conducted appeal rights explained and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Aug 2, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(6)(F) · Plan of correction due date: Aug 4, 2024

Incidental Medical and Dental Care (h)(6) … (6) The licensee shall be responsible for assuring that a record of centrally stored prescriptions.., which includes (F) Instructions, if any, regarding control and custody of the medication. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above to ensure that CSMDR were properly documented for accountability. R1’s medication was not documented properly. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 2, 2024

Plan of correction: Administrator agreed to schedule vendorized training for all staff and submit to CCL the vendor information and scheduled date of training. Training certifications to be submitted to CCL upon completion

Type of visit: POC

An unannounced case management visit was conducted by Licensing Program Analyst (LPA) Leslie Ngo-Castaneda. During the visit, LPA met with staff Gegham Amirkhanyan and briefly toured the facility. Staff contacted administrator Karine Sarkisyan over the telephone arrived at the facility at 3:45PM. The purpose of this visit is to follow up on the Plan of Corrections (POCs) that were issued during an complaint visit made on 5.31.2024 by LPA Leslie Ngo-Castaneda. Administrator e-mailed photos of corrections, however due to the nature of some citations, LPA Ngo-Castaneda visited the facility to check corrections in person. See POCs below: 1. Incident Report: During the complaint visit, administrator stated that one of their resident was taken to ER by paramedics. Administrator sent incident report filled-in incorrectly and incomplete on 6.21.2024. During today's visit, LIC 624 was submitted and filled-in correctly. Plan of Correction cleared. Exit interview conducted. A copy of the report was issued. Administrator understands that if outstanding POC is not met or extended by that a civil penalty may be issued.the state’s words, verbatim · CDSS document, Jul 9, 2024

Allegation investigated: Licensee does not ensure that staff follow food safety protocols. Staff do not ensure that resident's room is sanitary.

Licensing Program Manager(LPM) Nichelle Gillyard and Licensing Program Analyst (LPA) Leslie Ngo-Castaneda arrived at 8:20 am and met with the Administrator Karine Sarkisyan. The Administrator was informed of the reason for the visit. Entrance interview conducted. LPA/LPM conducted interviews with staff, attempted to interview resident in care and attempted to review records. LPA/LPM conducted a food inspection tour and a physical plant tour. Allegation: Licensee does not ensure that staff follow food safety protocols. Continue to LIC 9099-C Substantiated The complainant’s concern was that the licensee left food sitting out on the table for hours. While this was not observed and there were no other witnesses to cooperate the specifics of this allegation there were other food safety protocols not followed. At approximately 8:45 am LPA/LPM toured the kitchen area and initiated food service inspection. LPA/LPM observed an incontinent pad on the top shelf of the refrigerator to catch any spills from the shelf. Foods which include packs of hot dogs, cans of tomatoes sauce and a pot with a quarter red tomato and remnants of rice in a pan were observed to not be appropriately sealed and wrapped appropriately to protect from contamination. LPA/LPM observed a can of bug spray stored with potatoes and cooking pots under the kitchen sink. Therefore, after review of the information gathered the allegation, “Licensee does not ensure that staff follow food safety protocols” is substantiated. Deficiency issued. Allegation: Staff do not ensure that resident’s room is sanitary. The complainants concern that soiled depends(adult diapers) were left in the room for a lengthy period of time. While this was not observed and there were no other witnesses to cooperate the specifics of this allegation, LPA/LPM observed other sanitary issues which include two (2) half-full plastic portable urinals sitting on a table by the resident. This is a health and safety issue should the urinals falls spilling the urine. LPA/LPM observed a urine-stained mattress in an unoccupied room #1. LPA/LPM observed an ant infestation on top of an old plate with crumbs of food in room #4. The ant infestation was observed to also be within the residents clothing box. Therefore, after review of the information gathered the allegation, “Staff do not ensure that resident's room is sanitary”, is substantiated. Deficiency issued. Administrator was advised and a copy of this report given.the state’s words, verbatim · CDSS document, Jun 5, 2024 · control 31-AS-20240531162143

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(28) · Plan of correction due date: Jun 6, 2024

All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. This requirement is not met as evidenced by LPM/ LPA observe checmicals to be stored under the kitchen sink with food, which poses a potential health safety or personal rights risk to persons in care. This requirement is not met as evidenced by LPM/ LPA observed harmful chemicals/poison to be stored together with food under the sink.the state’s words, verbatim · CDSS document, Jun 5, 2024

Plan of correction: Harmful chemical/ poison that is located under the kitchen sink needs to be removed. Food and chemicals needs to be stores seprately. Food (sack of patatoes) under the sink needs to be discarded.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(24) · Plan of correction due date: Jun 5, 2024

Pesticides and other toxic substances shall not be stored in food storerooms, kitchen areas, or where kitchen equipment or utensils are stored.This requirement is not met as evidenced by LPM/ LPA observe checmicals to be stored under the kitchen sink with food, which poses a potential health safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 5, 2024

Plan of correction: Harmful chemical/ poison that is located under the kitchen sink needs to be removed and tuck away in a lock area.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

On 6.5.2024 Licensing Program Manager (LPM) Nichelle Gillyard and Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an unannounced Case Management - Deficiencies visit in conjunction with complaint control # 31-AS-20240531162143. LPM and LPA met with Administrator Karine Sarkisyan and explained the purpose of the visit. During the visit, LPM and LPA identified (2) staff that were not finger print cleared, nor was associated with the facility. Civil penalties will be assess during the visit. This is an immediate health and safety risk to residents in care. The following items were observed during the visit: Administrator disqualification to maintain records, the lack of knowledge and following the regulations of Title XXII. Insufficient staffing. Medication are attainable located at the kitchen cabinet. Chemicals are attainable located under the kitchen sink (Raid), under the sink of bathroom #1 (bleach), and laundry cabinet located by the hallway in between the entrance and living room (detergents). The kitchen is an open concept, a sofa is located in the kitchen area blocking the stove, which is a fire hazard. Common towels are used in bathroom #1 beside bedroom #2, no paper towels are available. Room #2 uses oxygen tank and there is no signage of 'Oxygen in used'. Facility temperature is not working. Room #1 and room #3 has administrator belonging in the closet and was using space for storage. (Technical advice was given to please remove personal belongings.) Continue to LIC 809-C LPA observe two (2) urinal bottles beside a resident in room #4 that is on a side table, this is health and sanitary issue because this could have spilled on the resident. LPA/ LPM observe room #1 to have a mattress that is soak/ stain in urine. No staff and residents records are available for LPM/LPA to review. Observation in room #3 to have screen/blinds to be off rack. Incident report for R1 needs to be submitted. Room #3 current resident in hospital, medication was administered by resident themselves. Solid waste needs to have tight fitting covers, not just a plastic bag, this was observe in the kitchen and bedroom #4. LPA offered the following Technical Violation (TV) was advised to the administrator regarding: A new facility sketch is needed when office will be converted to a staff living quarters. Two (2) day perishable food and seven (7) day non-perishable food needs to be available in the facility. Other: Form LIC 311F as requested is given to facility administrator at SIMPLE TOUCH BOARD AND CARE INC facility #197610429. Exit interview. Copy of this report was given to Administrator.the state’s words, verbatim · CDSS document, Jun 5, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(d)(1)-(5) · Plan of correction due date: Jun 19, 2024

(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (5). If the licensee is also the administrator, all requirements for an administrator shall apply. (1) Knowledge of the requirements for providing care and supervision... appropriate to the residents... (2) Knowledge of and ability to conform ... (3) Ability to maintain or supervise the maintenance of financial and other records. (5) Good character and a continuing reputation of personal integrity.This requirement is not met as evidenced by LPM/ LPA which poses a potential health.the state’s words, verbatim · CDSS document, Jun 5, 2024

Plan of correction: Administrator needs to re-train to be the administrator of the facility.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87411(a) · Plan of correction due date: Jun 19, 2024

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by LPM/ LPA observation that there was no staffing to for residents which poses a potential health safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 5, 2024

Plan of correction: Having the right number of staff is essential in order to provide care and supervision to residents. Need to hire another staff.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(1) · Plan of correction due date: Jun 6, 2024

Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. This requirement is not met as evidenced by LPM/ LPA observation that there was poison, cleaning solutions and disinfectant that are kept unlock for residents which poses a potential health safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 5, 2024

Plan of correction: Poison, cleaning solutions and disinfectant located under the kitchen, laundry room, and bathroom needs to be lock and inaccessible to residents.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(2) · Plan of correction due date: Jun 6, 2024

Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by LPM/ LPA observation that there was medication in kitchen cabinet from staff and medication was observed in room #2 that was not stored which poses a potential health safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 5, 2024

Plan of correction: All prescription medication needs to be stored and lock away. No medication of resident and staff should be accessible.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87618(b)(3)(b) · Plan of correction due date: Jun 6, 2024

Oxygen Administration - Gas and Liquid Ensuring that the use of oxygen equipment meets the following requirements: "No Smoking-Oxygen in Use" signs shall be posted in the facility and appropriate areas. This requirement is not met as evidenced by no signage as posted in room #2, which poses a potential health safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 5, 2024

Plan of correction: Oxygen sign needs to be place in appropriate area of the facility.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87303(a) · Plan of correction due date: Jun 6, 2024

Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by observation in the hallway that facility temperature is not working. Sofa was blocking the oven in the kitchen, which poses a potential health safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 5, 2024

Plan of correction: Change battery for facility termostat to operate temperate since its summer and would be very warm for residents. Sofa needs to be remove from the kitchen, this is a fire hazard.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87470(a)(1)(b)(4) · Plan of correction due date: Jun 6, 2024

Infection Control Requirements: (a) A licensee shall ensure that infection control practices are maintained as follows: After contact with blood, body fluids or other potentially infectious material, or contaminated surfaces. This requirement is not met as evidenced by LPA/LPM observation there are 2 urine bottles beside a resident in roo #4. Stained mattress in room #1 needs to be dispose, these poses a potential health safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 5, 2024

Plan of correction: Urine bottle needs to be discarded immediatelt and not kept beside resident in room #4. Mattress that is located in room #1 needs to be dispose.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(c) · Plan of correction due date: Jun 19, 2024

Maintenance and Operation: All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by observation of room#3 screen is off rack and bent, these poses a potential health safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 5, 2024

Plan of correction: Screen window in room #3 needs to be reapired.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(3) · Plan of correction due date: Jun 12, 2024

Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.the state’s words, verbatim · CDSS document, Jun 5, 2024

Plan of correction: Incident report needs to be submitted for resident fall to Regional Office (RO).

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303 · Plan of correction due date: Jun 19, 2024

Maintenance and Operation: Solid waste shall be stored and disposed of as follows: All containers, except movable bins, used for storage of solid wastes shall have tight-fitting covers on the containers; shall be in good repair; shall have external handles; and shall be leakproof and rodent-proof. This requirement is not met as evidenced by kitchen and bathroom #2 in bedrioom #4 has only trash bags hanging on a drawer handle for trash, these poses a potential health safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 5, 2024

Plan of correction: Proper disposable trash bin that has a tight fitting cover is needed within the facility.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87307 · Plan of correction due date: Jun 19, 2024

Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths...The use of common wash cloths and towels shall be prohibited This requirement is not met as evidenced by and bathroom #1 has no paper towel, these poses a potential health safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 5, 2024

Plan of correction: Have paper towel to wipe residents hands ready in all of the bathrooms.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Jun 19, 2024

Resident Records: (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by residents has no records which poses a potential health safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 5, 2024

Plan of correction: No records are available for LPA to review.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412 · Plan of correction due date: Jun 19, 2024

Personel records: The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This requirement is not met as evidenced by and staff has no records these poses a potential health safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 5, 2024

Plan of correction: Staff records needs to be ready for LPA to review.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(b) · Plan of correction due date: Jun 6, 2024

Prior to the Department issuing a license, the applicant, administrator and any adults other than a client, residing in the facility shall have a criminal record clearance or exemption. This requirement is not met as evidenced by two (2) staff was not associated with the facility which poses a potential health safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 5, 2024

Plan of correction: Association of staff to the facility is a must with Guardian in order to work within the facility.

Type of visit: Prelicensing

At 10:30am Licensing Program Analyst (LPA), Angela Panushkina conducted an announced Pre-Licensing visit to the above facility and met with Administrator, Karine Sarkisyan. Fire Clearance was approved on 10/19/2023 for a maximum capacity of six (6) residents, of which five (5) Non-Ambulatory and one (1) bedridden residents in room #5. The purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. The facility is a single-story building. Today's site visit consisted of LPA touring the physical plant inside and outside and observed the following: KITCHEN: The kitchen is equipped with a refrigerator, microwave oven and sink. At 10:45am, LPA observed adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). All knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents. Fire Extinguisher was last purchased on 10/19/23. BEDROOMS: There are five (5) bedrooms designated for client use. All bedrooms are furnished with beds, dressers and required bedding and linen. The bedrooms have sufficient closet space and have sufficient lighting. Auditory alarms were tested and observed to be operational. Facility will have awake staff. BATHROOMS: At 10:50am LPA observed three (3) bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured at 112.3°F. LPA observed appropriate grab bar and had non-skid mat. Continue on LIC809-C COMMON AREAS: The facility maintains a comfortable temperature at 70°F. The living room and dining appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility. LAUNDRY ROOM: The laundry room is located by the kitchen area. The washer/dryer appear to be in good condition. Laundry supplies are kept inaccessible when not in use with supervision. MEDICATION: The medication along with the facility staff/residents files will be kept in a hallway closet, by the room #4, and was kept locked and inaccessible to residents in care. SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors and carbon monoxide were located throughout the facility. At 11:00am they were tested and observed to be operational. SURROUNDING GROUNDS: In the back of the facility has sufficient yard space. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. The backyard is fenced. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients. There are no bodies of water GARAGE: The attached garage is currently being used for storage. LPA observe the garage locked and inaccessible to residents in care. Component III was conducted with the Administrator. Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB) and be notified by the CAB Analyst when your license has been approved. Exit interview was conducted and with a copy of this report was provided to the Applicant/Administrator.the state’s words, verbatim · CDSS document, Dec 19, 2023

Type of visit: Office

Component II completion: Successful Facility Type: Residential Care Facility for Elderly (RCFE) Application Type: Initial Capacity: 6 Census (if any clients in care): none COMP II Participants: Karine Sarkisyan, Applicant/Administrator Interview Method: Telephone interview On November 27, 2023 at 11:10 AM, applicant/administrator participated in COMP II. Identification of the applicant/administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant/administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility Operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing Requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General Provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing Readiness Exit interview conducted with Administrator/Applicant. Copy of report sent via email pdf and request to return sign copy by end of business day today.the state’s words, verbatim · CDSS document, Nov 27, 2023